RN Manager, Case Management / Utilization Management

Blue Cross Blue Shield of Massachusetts•Hingham, MA

10d•$104,580 - $127,820•Onsite

About The Position

We are seeking a dynamic leader to join our team as the Manager, Clinical Review. This role directs the utilization review clinical team operations for our Commercial plans. The manager will lead a clinical team, foster a culture of excellence, and ensure delivery of medically necessary, high-quality, and cost-effective care. This position is accountable for maintaining rigorous compliance with all regulatory and accreditation standards while driving strategic initiatives to improve member outcomes.

Requirements

A bachelor’s degree in nursing or related clinical field is required.
Must possess an active, unrestricted clinical license in Nursing or related clinical field (e.g., RN, NP, PA, etc.).
Must have the ability to secure equivalent licensure within the State of Massachusetts within 6 months of hire date.
A minimum of 5-7 years of professional experience and progressive leadership in utilization management within a health plan or health system setting preferred.
Proven experience overseeing utilization review in a managed care organization is highly desirable.
High school degree or equivalent required unless otherwise noted above

Nice To Haves

A master’s degree in healthcare administration, Public Health, Nursing, or a related clinical field is strongly preferred.

Responsibilities

Provide decisive leadership and direct supervision to a clinical staff team.
Execute a forward-thinking utilization management strategy that aligns with the company's goals.
Lead performance management, including hiring, professional development, mentorship, and performance evaluations to build a high-performing, engaged team.
Foster a culture of clinical excellence, empathy, and member-centered care.
Direct all utilization review functions, including pre-service, concurrent, and retrospective reviews, ensuring timeliness and adherence to evidence-based medical necessity criteria and internal medical policies.
Ensure the utilization management program maintains robust compliance with NCQA accreditation and other federal and state regulations.
Serve as the primary liaison between clinical teams, physician reviewers, and external organizations to resolve complex cases and clinical process issues.
Analyze complex utilization data to identify trends, patterns, and opportunities for clinical quality improvement.
Drive process improvement and identify opportunities to increase staff productivity and operational efficiency.